Survey Report for 101536

DEPARTMENT OF HEALTH AND HUMAN SERVICES		FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES		OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER	(X2) MULTIPLE CONSTRUCTION	(X3) DATE SURVEY COMPLETED
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION	101536	A. BUILDING __________ B. WING ______________	12/16/2019
NAME OF PROVIDER OR SUPPLIER	STREET ADDRESS, CITY, STATE, ZIP
OPUS CARE OF SOUTH FLORIDA	6900 SW 80TH ST, MIAMI, FL, 33143
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE		TITLE	(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID PREFIX TAG	SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY SHOULD BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)
L0678
L0678	36646 Based on record reviews and interviews, the Home Health Agency failed to include in patient's clinical record the Physician's order on 1 out of 4 sample patients (SP). SP #2. Findings include: Record review of SP #2's Medication Administration Record did not show any order for Morphine 15 mg (milligrams) SL (sublingual) every 2 hours around the clock; increase Lorazepam to 2 mg SL every 4 hours around the clock; change Hyoscyamine 0.125 mg to every 4 hours as needed for secretions. Change nebulizer treatments with Ipatropium to every 4 hours for 10/18/2019 Record review of SP #2's Medication Administration Sheet showed patient was given Morphine 15 mg SL every 2 hours on 10/18/2019 from 10:00 AM to 1900. On 12/16/2019 at 3:20 PM the Vice President (VP) of Clinical Management stated the nurse's documentation is everywhere but there is no documentation about the Physician Order received by the nurse for Morphine every 2 hours. They searched, and when the VP of Clinical Management, and the Director of Clinical Care came back to the conference room, both stated there was no Physician Order. The Vice President (VP) of Clinical Management added the nurse failed to put the order electronically so that the Physician can electronically sign the order.